23. Clinical Correlations DSA Flashcards
(140 cards)
1
Q
Absence of secretion of bile leading to white clay colored stools in conditions like cholelithiasis
A
Acholic
2
Q
Lack of appetite
A
Anorexia
3
Q
Any serious acute intra-abdominal condition (like appendicitis) attended by pain, tenderness, muscular rigidity, etc. for which emergency surgery must be considered
A
Acute abdomen
4
Q
Rumbling noise made by propulsion of gas through intestines
A
Borborygmi
5
Q
A profound and marked state of constitutional disorder; general ill health and malnutrition
A
Cachexia
6
Q
Stoppage or suppression of bile flow, due to factors within or outside the liver
A
Cholestasis
7
Q
Symptom denoting blood congealed and separated within gastric contents that takes its form when in contact with acidic environment
A
Coffee-ground emesis
8
Q
Acute paroxysmal abdominal pain
A
Colic
9
Q
Indicator of enlarged, nontender gallbladder secondary to pancreatic disease or cancer
A
Courvoisier’s sign
10
Q
Indicated by ecchymosis around the umbilicus (periumbilical) secondary to hemorrhage
A
Cullen sign
11
Q
A peptic ulcer of the duodenum in a patient with extensive superficial burns
A
Curling ulcer (“stress ulcer”)
12
Q
Peptic ulcer occurring from severe head injury or with other lesions of the CNS
A
Cushing ulcer
13
Q
Postprandial epigastric discomfort
A
Dyspepsia
14
Q
Difficulty swallowing
A
Dysphagia
15
Q
Abnormal tissue development, alteration in size, shape, and organization of cells
A
Dysplasia
16
Q
Edentulous
A
Having no teeth
17
Q
ERCP
A
Endoscopic retrograde cholangiopancreatography
18
Q
Eructation
A
Expulsion of swallowed air; aka burping
19
Q
EUS
A
Endoscopic ultrasound
20
Q
Gas or air in the GI tract expelled through the anus
A
Flatus
21
Q
Inflammation in the stomach with distinctive histologic and endoscopic features
A
Gastritis
22
Q
Gastric conditions where there is epithelial or endothelial damage without inflammation
A
Gastropathy
23
Q
GGT
A
Gamma-glutamyl transferase, used to determine the cause of elevated alkaline phosphatase (ALP)
24
Q
What is indicated by elevation in both GGT and ALP?
A
Liver disease
25
What is indicated by an elevated ALP with a normal GGT?
Not liver disease, usually bone
26
Flank ecchymosis secondary to hemorrhage
Grey Turner Sign
27
Foreign body sensation localized in the neck that does not interfere with swallowing and sometimes is relieved by swallowing; often occurs in the setting of anxiety or OCD. Often attributable to GERD
Globus pharyngeus
28
Protective response in muscle resulting from pain or fear of movement, voluntary vs involuntary
Guarding
29
Hematemesis
Vomiting blood
30
Passage of bright red blood or marron stools
Hematochezia
31
Icterus
Aka jaundice; yellowing of integument, sclera, and deeper tissues and excretions with bile pigments that have increased in plasma
32
KUB X-ray
Plain film of kidney, ureters, and bladder
33
LGIB
Lower GI bleeding
34
Dark colored stool consistent with broken down hemosiderin in bowel; typically malodorous, sticky, thick paste “tarry”
Melena
[described as melenic stools, NOT melanotic]
35
Lower abdominal pain in the middle of the menstrual cycle (feel ovulation), doesn’t cause rebound tenderness
Mittleschmerz
36
MRCP
Magnetic resonance cholangiopancreatography
37
Detected by palpating deeply under right costal margin during inspiration, and observing for pain and/or sudden stop in respiratory effort; tests for acute cholecystitis or cholelithiasis
Murphy sign
38
Subjective sensation of impending urge to vomit
Nausea
39
Severe intractable constipation caused by intestinal obstruction
Obstipation
40
Painful swallowing
Odynophagia
41
Abnormal presence of gas in the biliary system/bile ducts
Pneumobilia
42
Abnormal presence of air or gas in the mediastinum, may interfere with respiration and circulation, may lead to pneumothorax or pneumopericardium, occur spontaneously or as a result of trauma or path or after diagnostic procedure
Pneumomediastinum
43
Abnormal presence of air or gas in peritoneal cavity
Pneumoperitoneum
44
Sign associated with retrocecal appendix, manifested by RLQ pain with passive right hip extension
Psoas sign
45
Substernal burning sensation, aka heartburn
Pyrosis
46
Pain upon removal of pressure, rather than the application of pressure to the abdomen. Tests for peritoneal inflammation/acute abdomen
Rebound tenderness
47
Effortless reflux of liquid or gastric or esophageal food contents in the absence of N/V. The spontenous reflux of sour or bitter gastric contents into the mouth
Regurgitation
48
Peristalsis of the stomach and esophagus conducted with a closed glottis
Retching
49
Involuntary reflexive contraction of abdominal wall; abdomen feels hard
Rigidity
50
Pain in RLQ during left sided pressure, referred rebound tenderness seen in appendicitis
Rosving’s sign
51
Fatty, greasy, stools
Steatorrhea
52
Ineffectual and painful straining at stool or urination
Tenesmus
53
UGIB
Upper GI bleeding
54
Local defect, or excavation of the surface of an organ or tissue that is produced by the sloughing/shedding of inflamed necrotic tissue
Ulcer
55
Stone from kidney making its way through ureter to bladder, urine analysis will show hematuria
Ureterolithiasis
56
Palpable mass that is a LN in the left supraclavicular/sternoclavicular fossa
Virchow’s node
57
Queasiness, retching, and forceful ejection of upper gut contents from the mouth
Vomiting/emesis
58
T/f: causes of vomiting are isolated to the GI system
False
59
Causes of vomiting involved in visceral afferent stimulation
```
Infections
Mechanical obstruction
Dysmotility
Peritoneal irritation
Hepatobiliary or pancreatic disorders
Topical GI irritants
Postoperative
Cardiac disease
Urologic disease
```
60
What are some vestibular disorders that can cause vomiting?
Labyrinthitis
Meniere syndrome
Motion sickness
61
CNS disorders that can cause vomiting
Increased intracranial pressure
Migraines
Infections like meningitis or encephalitis
Psychogenic disoders like anorexia or bulemia
62
Irriation of chemoreceptor trigger zones can cause vomiting, including antitumor chemotherapy, medications/drugs, radiation, and systemic disorders
What are some medications that cause vomiting?
```
Opioids
Anticonvulsants
Antiparkinsonism drugs
Beta blockers, digoxin
Nicotine
Oral contraceptives
Cholinesterase inhibitors
Diabetic meds
```
63
Irriation of chemoreceptor trigger zones can cause vomiting, including antitumor chemotherapy, medications/drugs, radiation, and systemic disorders
What are some systemic disorders that cause vomiting?
```
Diabetic ketoacidosis
Uremia
Adrenocortical crisis
Parathyroid disease
Hypothyroid
Pregnancy
Paraneoplastic syndrome
```
64
Oropharyngeal dysphagia
Trouble initiating swallowing
65
Causes of oropharyngeal dysphagia
```
Neurologic disorders (MS, GB)
Muscular and rheumatologic disorders
Metabolic disorders (cushings, thyrotoxicosis)
Infectious disease (polio, diphtheria, syphilis)
Structural disorders (zenker diverticulum, tumors)
Motility disorders (UES dysfunction)
```
66
Causes of esophageal dysphagia
Mechanical obstruction - solid foods worse than liquids = Schatzki ring, peptic stricture, esophageal cancer, eosinophilic esophagitis
Motility disorder - solid AND liquid foods = achalasia, diffuse esophaeal spasm, scleroderma, ineffective motility
67
Condition caused by loss of peristalsis in the distal 2/3 smooth muscle of esophagus resulting in impaired relaxation of LES
Achalasia
68
Achalasia results from denervation of the esophagus, resulting primarily from what?
Loss of NO producing inhibitory neurons in the myenteric plexus
69
Symptoms of achalasia
Gradual, progressive dysphagia for solids and liquids, resulting in regurgitation of undigested food
substernal discomfort
Weight loss
70
2 primary diagnostic techniques for achalasia
Barium esophagogram - shows birds beak sign in distal esophagus. EGD endoscopy is performed to r/o mechanical obstruction
Esophageal manometry confirms diagnosis d/t complete absence of normal peristalsis and incomplete LES relaxation with swallowing
71
What disease is known as “secondary achalasia”?
Chagas disease
72
How is the esophageal dysfunction distinguished in primary vs. secondary achalasia?
They are indistinguishable! Important to consider chagas disease in patients from endemic regions like mexico, central, and south america
Chagas patients may exhibit other systemic signs such as chagomas or romana’s sign at the portal of entry
73
How is the physiology of the esophagus affected in achalasia in terms of peristalsis, esophageal sphincter funciton, and resting pressure at those sphincters?
Impaired peristalsis
Incomplete LES relaxation during swallowing (stays closed during swallowing resulting in the backup of food)
Elevation of LES resting pressure
74
What are some “red flags” to watch for when a patient presents with dyspepsia and epigastric pain?
```
Dysphagia (especially progressive)
Odynophagia
Hematemesis
Melena
Unintentional weight loss
Persistent vomiting
Constant/severe pain
Unexplained iron deficiency anemia
Palpable mass
LAD
Family hx of upper GI cancer
```
75
How is the physiology of the esophagus affected in GERD?
LES relaxes abnormally or weakens, allowing reflux to occur
76
What condition accounts for 50% of upper GI bleeding?
Gastric or duodenal PUD
77
When is the presence of an ulcer considered PUD?
When ulcer extends through muscularis mucosae and is over 5 mm in diameter
78
Symptoms of PUD
Epigastric pain described as gnawing, dull, sharp, burning, aching, or hunger-like
Most patients have periodic episodes
79
Signs of gastrointestinal bleeding
Coffee grounds emesis, hematemesis, melena, or hematochezia
80
T/F: PE is often normal in uncomplicated PUD
True; may find mild, local epigastric tenderness to deep palpation though
81
Describe characteristics of H pylori bacteria
```
Flagella
Motile
Microaerophilic
Spiral (curved, helix)
Gram negative bacilli
Urease producing
Colonizes gastric antral mucosa
```
82
What conditions are associated with H pylori?
PUD (usually duodenal)
Chronic gastritis
Gastric adenocarcinoma
MALT lymphoma
83
What strain of H pylori significantly increases risk of ulcer?
Cag-A toxin positive strain
84
How is chronic gastritis due to H pylori distinguished from Zollinger Ellison when they both elevate gastrin levels?
ZE will elevate above 1000, chronic gastritis typically does not go that high
85
Risk factors for H pylori
```
Poverty
Overcrowding
Limited education
Ethnicity
Rural
Birth outside US
```
86
Transmission of H pylori
Likely Person to person via fecal oral route
Although exact mode is not known
87
Methods of detection of H pylori and the important consideration prior to running these tests
Best:
Urea breath test
Fecal Ag test
Other:
Serum Ab test
Upper endoscopy with gastric biopsy
**need to have patient stop PPI x14 days prior to fecal and breath tests or high chance of false negative
88
How does H pylori damage gastric mucosa?
Releases cytotoxins that breakdown mucosal barrier and underlying cells
Urease allows bacteria to colonize gastric mucosa, converts urea to NH3 which alkalinizes the local environment
89
Which is more common, gastric or duodenal ulcers?
Duodenal
90
How does location of ulcer differ in PUD associated with gastric vs. duodenal ulcers?
Gastric: typically in lesser curvature of antrum
Duodenal: anterior wall lining of proximal duodenum; multiple ulcers distal to second portion of duodenum
91
How does the pathology of PUD distinguish gastric vs. duodenal ulcers in terms of gastric acid production?
Gastric ulcers result in decreased acid secretion
Duodenal ulcers result in increased acid secretion
92
How does symptom description change in gastric ulcers vs. duodenal ulcers?
Gastric: sharp, burning, epigastric pain that worsens 30 min-1.5 hours after eating
Duodenal: gnawing epigastric pain that worsens 3-5 hours after eating, may be temporarily relieved by food/eating
93
How does NSAID use lead to risk of upper GI ulcers?
MOA ultimately inhibits COX1 and 2, prostaglandins, and NO which leads to decreased protection of gastric and duodenal mucosa
Damage is within epithelial layers with resorption effects, or macroscopically with actual tissue damage
94
Possible etiologic factors for apparently H pylori and NSAID-negative ulcers
```
Smoking history
Comorbid disease
H pylori that has escaped detection
Surreptitious NSAID use
Neoplasia, infection, infiltrative disease
Acid hypersecretion
Ischemic mechanisms
```
95
What condition should be considered in the following presentation:
Intractable/recurrent/severe ulcer disease associated with ulcers in atypical locations, enlarged gastric folds
Ulcer is associated with secretory diarrhea, steatorrhea, weight loss, N/V, significantly elevated fasting gastrin levels and positive secretin stimulation test, epigastric pain/GERD, and hematemesis/hematochezia/melena
Zollinger-Ellison Syndrome-Gastrinoma
96
Describe tumor characteristics of gastrinoma
Slow growing
Sometimes pancreatic
Most commonly in duodenum
Occasionally in LNs
>60% malignant, >1/3 have already metastasized to liver
97
You evaluate a patient and diagnose them with a ZES gastrinoma, hyperparathyroidism based on increased calcium levels, and pituitary neoplasm. What condition do they have, which has a 25% association rate with ZES gastrinomas?
Multiple Endocrine Neoplasia type 1 (MEN 1)
98
Diagnosis of ZE-gastrinomas are suggested first by large mucosal folds on endoscopy or upper GI imaging. What typically confirms the diagnosis?
Serum gastrin >1000 ng/L (fasting, w/o PPI)
+secretin stimulation test (would be negative in other causes of hypergastrinemia)
CT and MRI to look for large hepatic metastasis and other primary lesions
99
How does ZES lead to steatorrhea?
Gastrin secreting tumor leads to increased H+ secretion by parietal cells, which overwhelms buffer capacity of HCO3 in duodenum
Low duodenal pH inactivates pancreatic lipases, leading to fatty stools
100
Differential diagnosis of epigastic pain (dyspepsia)
```
PUD
Functional dyspepsia (no explanation)
Atypical gastroesoph. reflux
Gastric cancer
Food poisoning
Viral gastroenteritis
Biliary tract disease
```
101
Severe epigastric pain is atypical for PUD unless complicated by a perforation
What are other causes of severe epigastric pain?
```
Acute pancreatitis
Acute cholecystitis/cholelithiasis
Esophageal rupture
Gastric volvulus
Gastric/intestinal ischemia
Ruptured AAA
Myocardial ischemia
```
102
Differential dx of upper GI bleed
```
PUD
Erosive gastritis
Arteriovenous malformations/angioectasis
Mallory-weiss tear
Esophageal varices
```
103
What is the diagnostic study of choice for evaluating PERSISTENT heartburn, dysphagia, odynophagia, or structural abnormalities detected on barium esophagography?
Upper endoscopy
[aka esophagogastroduodenoscopy = EGD]
104
How is an EGD both diagnostic and therapeutic?
Gives direct visualization and allows biopsy of mucosal abnormalities and of normal appearing mucosa
Allows for dilation of strictures
105
What diagnostic test is used to differentiate between mechanical lesions and motility disorders?
Barium esophagography
[aka barium swallow xray/barium esophagram]
106
A barium study is more sensitive for detecting esophageal narrowing d/t what types of conditions?
Rings
Achalasia
Proximal esophageal lesions
107
What is esophageal pH recording and impedance testing?
Techniques using combined pH and multichannel intraluminal impedance allow assessment of acid and nonacid liquid reflux
108
What is the purpose of esophageal manometry?
Assesses esophageal motility
Determines the location of the LES to allow precise placement of a conventional electrode pH probe
Establishes etiology of dysphagia in patients in whom mechanical obstruction cannot be found, especially if achalasia is suspected by endoscopy or barium study
109
What is suspected if free air is seen under the right side of the diaphragm on an upright CXR?
Perforated hollow organ
SURGICAL EMERGENCY
110
CT has no part in the primary detection of gastric ulcers, when is CT used for ulcers?
Detection of subphrenic and other collections that may occur after a perforation of a gastric ulcer
111
What is HIDA scan? What is an abnormal finding?
Hydroxy iminodiacetic acid scan
Abnormal = gallbladder does not show up
HIDA + CCK checks gallbladder ejection fraction; if low (<38%), then biliary dyskinesia is suspected
112
What type of ultrasound can detect tumors in the pancreas and other organs surrounding the GI tract?
Endoscopic ultrasound (EUS)
113
What is ERCP - Endoscopic Retrograde Cholangiopancreatography - used for?
To visualize hepatobiliary and pancreatic ducts, can also provide therapeutic intervention
114
What is MRCP - Magnetic Resonance Cholangiopancreatography - used for? How does it differ from ERCP?
Does the same thing as ERCP - visualizes hepatobiliary and pancreatic ducts - but it is NONINVASIVE and CANNOT provide intervention (opposite ERCP)
115
Most people refer to LFTs as AST/ALT transaminases, alkaline phosphatase (ALP), and bilirubin, (LDH and GGT). Why is LFT a misnomer in these cases?
These can come from other sources, and if they do come from the liver they indicate liver damage moreso than function
116
Most people refer to LFTs as AST/ALT transaminases, alkaline phosphatase (ALP), and bilirubin, (LDH and GGT). This is a misnomer.
What are examples of TRUE LFT’s?
PT/INR
Albumin
Cholesterol
117
What is in a CBC?
```
WBC
Hgb
Hct
MCH
MCHC
MCV
RDW
RBC count
Platelet count
```
118
What is in a CBC with differential?
Same stuff as a CBC, with percentage and absolute differential counts (PMN, lymph, baso, eos, mono)
119
MCV
Mean corpuscular volume
120
MCH
Mean corpuscular hemoglobin
121
MCHC
Mean corpuscular hemoglobin concentration
122
RDW
Red cell distribution width
123
What is included in a BMP?
```
BUN
BUN:Cr ratio
Ca
CO2
Cl
Creatinine
eGFR
Glucose
Potassium
Sodium
```
124
A comprehensive metabolic panel includes the same things as a BMP, with what additions?
```
Albumin:Globulin ratio
Albumin
ALP
AST/SGOT
ALT/SGPT
Total bilirubin
Total globulin
Total protein
```
125
Mild elevations in serum aminotransferases where ALT is predominant may indicate what conditions?
```
Chronic hepatitis B, C, and D
Acute viral hepatitis
Steatosis/steatohepatitis
Hemochromotosis
Medications/toxins
Autoimmune hepatitis
Alpha-1 antitrypsin deficiency
Wilson disease
Celiac disease
Glycogenic hepatopathy
```
126
Mild elevations in serum aminotransferases where AST is predominant may indicate what conditions?
Alcohol related liver injury
| Cirrhosis
127
Mild elevations in serum aminotransferases coming from non-hepatic sources may indicate what conditions?
```
Strenuous exercise
Hemolysis
Myopathy
Thyroid disease
Macro-AST
```
128
Severe elevations in serum aminotransferases greater than 15x normal may indicate what conditions?
```
Acute viral hepatitis (A-E, herpes)
Medications/toxins
Ischemic hepatitis
Autoimmune hepatitis
Wilson disease
Acute bile duct obstruction
Acute budd-chiari syndrome
Hepatic artery ligation
```
129
Lipase and amylase labs may be considered when looking for signs of ______
Pancreatitis
130
GGT, fractionate bilirubin, and PT/INR are labs to consider when assessing the _____
Liver
131
Osteopathic considerations of the GI system include parasympathetics which supply the upper GI tract (esophagus thru transverse colon) via the _____, _____ vertebral levels and _____ nerve
As well as the lower portion of the GI tract (descending colon, sigmoid, and rectum) via the _____ vertebral levels and _______ nerves
OA, AA, Vagus
S2-S4; pelvic splanchnic
132
Sympathetic levels of viscerosomatics corresponding to the:
Appendix
Esophagus
Stomach
Appendix = T12
Esophagus = T2-8
Stomach = T5-9
133
Sympathetic levels of viscerosomatics corresponding to the:
Liver
Gallbladder
Small intestine
Liver = T6-9
Gallbladder = T6-9
Small intestine = T5-9, T9-12
134
Sympathetic levels of viscerosomatics corresponding to the:
Colon
Pancreas
Colon = T9-L2
Pancreas = T5-11
135
What type of ulcer requires follow up to make sure it has completely resolved because it can be a sign of malignancy?
Gastric ulcer
136
How does ZES lead to its characteristic finding of enlarged gastric folds?
The gastrinoma secretes large quantities of gastrin, leading to increased H+ secretion by parietal cells which exerts a trophic effect, leading to increased parietal cell mass and enlarged gastric folds
137
What parasite causes secondary achalasia?
Trypanosoma cruzi
[causes chagas disease]
138
Differentiating upper vs. lower GI bleeding is often characterized based on whether it is proximal or distal to what landmark?
Ligament of treitz
139
You diagnose your patient with MALT lymphoma associated with an active H. pylori infection. You first administer antibiotics to get rid of the H. pylori infection. What effect does this have on the cancer?
Cures it!
140
Not all infections with H. pylori lead to ulcers. What component of H. pylori makes the development of an ulcer far more likely?
Exotoxin (vacuolating toxin that causes gastric mucosal injury)
